Nov05.html

University of Virginia Nutrition
Support
E-Journal Club
November 2005

Greetings,

We had a wonderful time during our November traineeship, and hosted
4 trainees from New Haven , CT ; Henderson , Kentucky and Dhahran ,
Saudi Arabia . The weather turned cold (for Virginia ) by week’s
end, and the last of our beautiful fall foliage is near spent.

This is a prospective, but observational study of 231 medical ICU
patients that investigated energy expenditure and actual delivery of
tube feedings. The goal was to follow patients who received
enteral nutrition (EN) for at least 7 days. The authors also
commented on mortality, in relation to the amount of nutrition that was
provided.

EN was administered as a bolus every 2 hours over a 14-hour period
from 08:00 to 22:00 hrs. The goal was to administer at least 25
kcals/kg, or a maximum of 2000 mL formula/day, of a 1 calorie/mL
feeding by day 4 of the study.

Results:

Ultimately only 61 patients received EN for at least 7 days, and
patients were followed for a mean of 12.5 +/- 2.5 days. Twenty-two
patients were converted to nasojejunal tube feeds after residuals
exceeded 300mL, and supplemental parenteral nutrition was provided on
18.7% of feeding days.

Patients received an average of 86.2% (+/- 30.4%) of ordered volume;
full volume of feeding was delivered on 78.9% of patient days.
Enteral feedings were interrupted on 241 feeding days, but due to the
14-hr feeding cycle the interruption was compensated 31% of the time by
extending the feeding period into the night. The goal of meeting
target tube feedings by day 4 was achieved in 46 patients (75%).
The remaining 15 patients met target volume after 10.4 +/- 5.7
days. The 15 patients who did not meet feeding targets by day 4
had a higher APACHE-II score, increased need for mechanical
ventilation, and significantly increased mortality (p= <
0.002).

Authors Conclusions:

The conclusions were that a high delivery-to-prescription rate could
be achieved with a standardized protocol in critically ill medical
patients, and that enteral feeding intolerance is associated with a
high mortality rate.

Evaluation:

The major point made by the group was that since this was an
observational study that it is important to realize that no
cause-and-effect conclusions can be made about the feeding intolerance
and patient mortality. There would be a clear selection bias,
with more critically ill patients experiencing a higher mortality and
greater (real and perceived) feeding intolerance. The target
feeding goals were modest, and the feeding protocol may not translate
well to facilities with a protocol for continuous feeding. The
use of a 14-hr feeding cycle did appear to have the advantage of
allowing time to compensate for missed feeding. Of note, is that
36% of the patients were converted to small bowel feedings, and since
the methods-section describes only bolus feedings, it appears that
those patients who were converted to small bowel tubes may have
tolerated bolus feedings.

Take home message:

This study is consistent with several others- patients do not
receive full feeds in the ICU. There was no comparison made to
another protocol – this is an observational study, so there is no
support for the use of this protocol over any other. No
cause-and-effect statements can be made about feeding intolerance and
outcome based on an observational study.

--------------------------------------------------------------------------------------------------------"A
habit of basing convictions upon evidence, and of giving to them only
that degree or certainty which the evidence warrants, would, if it
became general, cure most of the ills from which the world
suffers."

Check out the latest Practical Gastroenterology article at:www.uvadigestivehealth.org
Scroll down to GI Nutrition on the far left column and click on
link
Then scroll down to box with links within the nutrition site
Nutrition Articles in Practical Gastroenterology is in the left
column.